Healthcare Provider Details

I. General information

NPI: 1265162994
Provider Name (Legal Business Name): AMY KALLISTA GERHART BSN, RN, CNRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 SW 12TH ST UNIT 106
DES MOINES IA
50309-4317
US

IV. Provider business mailing address

412 SW 12TH ST UNIT 106
DES MOINES IA
50309-4317
US

V. Phone/Fax

Practice location:
  • Phone: 507-993-8070
  • Fax:
Mailing address:
  • Phone: 507-993-8070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0800X
TaxonomyNeuroscience Registered Nurse
License Number00381300
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number164264
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: